Welcome Sheet



    We currently use an automated system to send you text messages, emails and voice recordings for appointment reminders and notifications about glasses and contact lenses. Check this box if you prefer to not to use this system: Don't Use

    Are we using vision insurance for your visit?

    If you checked YES, who is the responsible party for billing any insurance copays, overages or non-covered services?

    If you checked SPOUSE or PARENT, please provide their contact information:

    Do you have allergies (environmental, drug, etc.)?

    Do you use tobacco products?

    Do you drink alcohol?

    Do you use illegal drugs?

    Note any family history [parents, grandparents, siblings, children (living or deceased)] and indicate maternal or paternal.

    Blindness

    Cataract

    Crossed Eyes

    Diabetes

    Detached Retina

    Glaucoma

    Heart Disease

    High Blood Pressure

    Macular Degeneration

    Do you currently have, or have you ever had, any problems in the following areas? Please check all that apply:

    Eyes













    Bones, Joints, Muscles



    Neurological



    Psychiatric



    Ears, Nose, Mouth, Throat




    Respiratory


    Lymphatic/Hematologic

    I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I certify that the information given by me in applying for insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me to obtain payment of my insurance benefits.

    If signing as a personal representative of the patient, describe the relationship to the patient and the source of authority to sign this form.


    Note: Please allow up to 10 seconds for the form to submit.